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The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Artesia Palms Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, dementia, and generalized anxiety disorder, and with severely impaired cognition per MDS, had multiple documented elopement attempts in SBAR notes, including attempts to climb or jump over a facility fence. Despite these events, an RN supervisor, the MDSC, and the ADON repeatedly completed Elopement and Wandering Risk Observation/Assessment forms indicating the resident only expressed plans to leave but had not attempted to do so, omitting the prior elopement attempts. The DON later acknowledged these assessments were completed incorrectly and that they did not accurately reflect the resident’s elopement history, contrary to the facility’s charting and documentation policy requiring objective, complete, and accurate records.
Pureed Bread Not Prepared to IDDSI Level 4 Standard: The facility failed to provide pureed bread in a smooth, lump-free form for 26 residents on a pureed diet. During tray line observation and staff interviews, the bread was described as lumpy, with milk separating on top, small bread pieces present, and residue remaining in the mouth. Staff stated the bread was only blended a little and not as long as other pureed foods, despite the facility recipe and IDDSI Level 4 guidance requiring a smooth, non-lumpy product with no liquid separation.
Call Light Not Within Reach: A resident with Parkinson’s disease, quadriplegia, dementia, and severe communication impairment had a soft touch call light that was supposed to remain within reach, but it was observed hanging over a tube feeding pump at the bedside and not accessible. The DON stated the device needed to be within the resident’s reach to work properly, and the facility policy required the call light to be within easy reach when the resident was in bed.
A resident with dementia, schizoaffective disorder, and psychosis was receiving Seroquel for schizophrenia/paranoia, but the facility monitored non-specific behaviors such as delusional thoughts and difficulty to redirect instead of resident-specific, measurable target behaviors. The RNS and PNP both stated the monitored behaviors were not specific to the resident’s diagnosis, and the DON stated inaccurate behavior data could delay GDR decisions and lead to continued unnecessary psychotropic use.
The facility failed to code MDS assessments accurately for two residents with DM. One resident’s MDS did not show an active DM diagnosis or insulin use despite an insulin order, and another resident’s MDS incorrectly showed insulin injections even though the resident had an oral DM medication and no insulin order. The MDSC and DON acknowledged the coding errors, and the facility policy required MDS information to match the resident record and observations.
Incomplete PTSD Care Planning: A resident with PTSD, schizoaffective disorder, bipolar disorder, and legal blindness did not have a comprehensive person-centered care plan that identified trauma triggers or individualized interventions. The care plan noted risk for psychosocial/emotional trauma and a goal for the resident to feel safe and secure, but the RNS stated it did not specify the resident’s triggers. The SSD noted the resident’s PTSD was related to homelessness and reported assault, yet no PTSD assessment was documented.
A resident with dementia, schizoaffective disorder, and a history of falls had repeated fall incidents and IDT recommendations for added fall precautions, including a falling star program, bilateral landing mats, a low bed, a 1:1 sitter, and wheelchair use when tired. The care plan listed some fall interventions, but it did not reflect the IDT-recommended updates or revision after the actual falls, and the RNS stated those interventions should have been included.
A resident with HTN, dysphagia, type 2 DM, and a history of falls had multiple physician-ordered monitoring requirements, including checks for bleeding, behavior, hyperglycemia, hypoglycemia, dehydration, pain, and VS. The MAR did not show these monitoring orders were completed during the night shift, and the DON verified that licensed nurses were responsible for carrying out the ordered monitoring.
Failure to provide ordered bilateral floor mats: A resident with muscle weakness, paranoid schizophrenia, moderate cognitive impairment, and fall risk factors was repeatedly observed in bed with a floor mat on only one side, despite an order for mats on both sides. The LVN and DON confirmed the order called for bilateral floor mats for safety and security, and the DON stated they should have been implemented right away.
Failure to identify PTSD triggers and individualize trauma-informed care: A resident with PTSD, schizoaffective disorder, bipolar disorder, and legal blindness had care plan language noting risk for psychosocial/emotional trauma, but staff did not document specific triggers or a PTSD assessment. SSD records noted PTSD related to homelessness, and the public guardian reported prior assault by an ex-boyfriend while the resident was homeless. RNS and DON stated the resident’s triggers should have been identified to support individualized care and prevent re-traumatization.
Resident Room Size Requirements Not Met: The facility failed to ensure 17 multi-bed resident rooms met the required square footage per resident. A review of the accommodation analysis showed several 4- and 5-bed rooms on two units measured below the 80 sq. ft. per resident standard. Observations found residents had space to move freely and room for mobility aids, and the ADM acknowledged the rooms did not meet the requirement. The facility policy stated bedrooms must provide at least 80 sq. ft. per resident in double rooms and support privacy and adequate nursing care.
A CNA failed to report an unwitnessed fall and assisted a resident with dementia, Parkinson's Disease, and epilepsy back to bed without notifying a nurse. The fall was only reported later by the resident to an LVN, resulting in a delay in care. The facility did not initiate a neurological assessment as required by policy before the resident was transferred to a hospital for further evaluation.
A resident with moderate cognitive impairment and psychiatric diagnoses physically assaulted his cognitively impaired roommate in a shared restroom, resulting in facial injuries, a nasal bone fracture, and skin tears. The incident was witnessed by a CNA, and the injured resident was transferred to a hospital for evaluation and treatment. Facility leadership confirmed the event was considered physical abuse and acknowledged the residents' right to be free from such harm.
A resident with a history of wandering and cognitive impairment was not provided with required 1:1 supervision, allowing them to enter another resident's room. The other resident, who had a history of aggression and psychiatric diagnoses, physically assaulted the wandering resident, resulting in facial injuries and a scalp hematoma. Staff interviews confirmed that supervision protocols and abuse prevention policies were not followed, and the incident was unwitnessed until staff responded to yelling.
Two residents with cognitive impairments and identified elopement risk were able to leave the facility unsupervised after staff failed to recognize them and did not follow established monitoring protocols. The individuals were missing for over a day before being found and required hospital evaluation for altered mental status and a UTI.
The facility did not provide required training on elopement prevention to new and existing staff, resulting in two residents leaving a secured area and exiting through the front door without supervision. Staff files lacked documentation of elopement training, and interviews confirmed that training focused on response rather than prevention or resident identification.
The facility did not provide written bed hold notices to the responsible parties of two residents with cognitive impairments within 24 hours of their transfer to a hospital, as required by policy. Although verbal notification was given and information was provided at admission, there was no documented evidence that written notices were created or delivered after the transfers.
A resident with Parkinson's Disease and severe cognitive impairment experienced an unwitnessed fall with a head injury. Despite physician orders and facility protocol requiring scheduled neurological checks, an LVN missed 11 assessments over several days. The DON confirmed the assessments were not completed as required, resulting in incomplete neurological monitoring.
A resident with Parkinson's Disease, muscle weakness, and severely impaired cognition experienced an unwitnessed fall resulting in a left eyebrow injury. Although the physician was notified and neuro checks were ordered, there was no documented Nursing Fall Assessment completed by nursing staff, as required by facility policy to guide interventions after a fall.
Licensed nurses failed to ensure informed consent was obtained from residents or their responsible parties before administering antipsychotic and psychotropic medications. In several cases, medications were given before consent was documented, and consents were sometimes obtained by nurses instead of the prescribing provider, contrary to facility policy. This resulted in residents receiving medications without being fully informed or having the opportunity to consent or refuse.
A facility failed to follow a physician's order for an orthopedic follow-up for a resident with a fractured radius, resulting in a delayed appointment. Additionally, the facility did not properly assess another resident's skin condition, missing signs of swelling and scratches. These deficiencies highlight lapses in communication and adherence to care protocols.
The facility failed to ensure appropriate use of psychotropic medications for three residents. One resident was given Lurasidone without a justifiable diagnosis, another lacked proper side effect monitoring for Seroquel and Trazodone, and a third had an incorrect order for Risperdal. The facility's policies on medication use were not followed, leading to unnecessary and potentially harmful medication administration.
The facility failed to label and date an unopened box of croissants in the dry storage area, leading to spoilage as one croissant had a greenish fuzzy spot. The dietary director confirmed the lack of labeling and the importance of adhering to the facility's policy and FDA guidelines to prevent foodborne illnesses.
The facility failed to accurately document RNA services for several residents, leading to discrepancies between RNA documentation and prescribed orders. One resident's RNA flowsheet did not match therapy recommendations, while another had missing documentation for RNA services. Additionally, an RNA task was not resolved when services were discontinued, causing inaccurate service reflection. These issues contradict facility policy requiring accurate documentation to ensure appropriate care.
An LVN failed to perform hand hygiene while checking lunch trays, touching her mask and hair, and handling food items without sanitizing her hands. This was against the facility's infection control policies, which emphasize hand hygiene to prevent cross-contamination.
A resident on anticoagulant therapy was not provided with a medical alert bracelet as required by their care plan. Despite the care plan indicating the need for the bracelet, the resident reported never receiving one, and this was confirmed by staff observations. The DON acknowledged the importance of following care plan interventions to ensure appropriate care.
A facility failed to ensure a Restorative Nursing Aide locked both wheelchair brakes before assisting a resident with Alzheimer's and COPD into a standing position. The resident, at moderate fall risk, was assisted with walking exercises, but only the right brake was locked, posing a fall risk. Interviews with the Director of Rehabilitation and DON confirmed the necessity of locking both brakes, as outlined in the facility's policy.
The facility failed to dispose of needles properly and maintain accurate drug records, risking safety. Enoxaparin injections were found in regular trash instead of sharps containers, and narcotic sheets for controlled substances lacked necessary documentation. The DON acknowledged these issues, which contradict the facility's policies.
The facility failed to label a TB PPD vial and a Rybelsus bottle with open dates, as observed during a survey. An LVN in the Villa unit found a TB PPD vial without an open date, and another LVN in the Terrace unit identified a Rybelsus bottle lacking an open date. The DON confirmed that medications should be labeled with open dates to ensure efficacy, as per the facility's policy.
The facility failed to meet room size requirements for 45 rooms and did not accommodate a resident's wheelchair mobility needs. The resident, with muscle weakness and osteomyelitis, struggled to maneuver due to narrow space between beds, potentially hindering emergency evacuation.
A resident with severe cognitive impairment was hit on the nose by another resident in the smoking patio area, resulting in a nosebleed and hospital evaluation. Despite staff presence, the altercation occurred quickly, highlighting a lack of adequate supervision. The facility's policy on abuse prevention was not effectively implemented.
A resident with atrial fibrillation receiving Warfarin experienced significant medication errors due to the facility's failure to administer the medication as ordered and monitor critical lab values. The resident received overlapping doses of Warfarin, leading to critically high INR levels and a subsequent transfer to a hospital with a subdural hematoma. The facility's lack of follow-up with the physician on critical lab results contributed to the adverse event.
A facility failed to ensure a comprehensive Medication Regimen Review (MRR) was conducted by the Consulting Pharmacist (CP) for a resident on Warfarin, leading to unnecessary doses and potential adverse effects. The resident, with atrial fibrillation, had varying Warfarin dosages, but the MRRs lacked recommendations on administration or lab results. Interviews revealed the CP did not make recommendations due to lack of knowledge about the physician's dosing protocol, despite the facility's policy requiring thorough monthly reviews.
A resident with atrial fibrillation and on anticoagulant therapy had critically high INR levels, but the facility staff failed to notify the physician within the required timeframe. Despite the facility's policy, there was no follow-up with the physician or contact with the Medical Director after the initial notification, posing a risk for the resident.
A facility failed to clarify a physician's order for aspirin, resulting in a three-month discrepancy in the dosage administered to a resident with a history of stroke. The physician ordered 81 mg, but the facility documented and administered 1 mg. Interviews revealed that licensed nurses did not follow the procedure to verify and clarify medication orders, leading to potential confusion and miscommunication about the resident's care needs.
A facility failed to document the indication and effectiveness of pain medication for a resident with osteomyelitis and dementia. The MAR lacked details on the location of pain and the effectiveness of acetaminophen and ibuprofen administered. Interviews revealed a lack of awareness about documenting pain specifics, contrary to facility policies.
A resident with osteomyelitis and dementia experienced a fall, and the facility failed to accurately document medication administration and pain assessment. The MAR showed discrepancies in the timing and documentation of pain medication, and the nurse did not record the location or effectiveness of the pain relief. The resident sustained knee abrasions that were not initially documented, highlighting a lapse in following the facility's documentation policies.
A resident with legal blindness was left unsupervised during meals, leading to food spills and feelings of neglect. Despite care plan requirements for supervision, staff failed to assist, impacting the resident's dignity and well-being. Observations and interviews revealed a lack of adherence to facility policies on resident care and dignity.
A resident with dementia and other conditions was denied readmission to a facility after hospitalization for behavioral symptoms, as their stay exceeded the seven-day bed-hold policy. Despite the facility's policy allowing for return after the bed-hold period, staff cited CMS reimbursement concerns and the facility's special-focus status as reasons for denial. This resulted in the resident remaining unnecessarily at the hospital, contrary to the facility's procedures.
The facility failed to ensure complete and accurate documentation of Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) for three residents, leading to potential treatment against their wishes during emergencies. Residents with serious medical conditions and impaired decision-making capacity had incomplete POLSTs, missing critical information such as physician details and witness signatures, and lacked proper documentation of AD discussions.
The facility failed to accurately document the MDS for two residents, leading to potential negative impacts on their care plans. One resident's MDS incorrectly indicated the presence of an indwelling catheter, while another's skin condition was misclassified. These errors were confirmed by the IMDSC and could lead to inappropriate treatment.
The facility failed to provide adequate personal hygiene care for several residents, resulting in deficiencies in grooming and oral hygiene. Residents were observed with long, untrimmed fingernails and poor oral hygiene, despite being dependent on staff for these needs. Staff acknowledged the responsibility for maintaining residents' hygiene, but the facility's policies were not followed, leading to these deficiencies.
The facility failed to accurately document RNA tasks for two residents, leading to discrepancies in records. One resident's records did not reflect PROM exercises and the use of an abductor pillow, despite orders and summaries indicating these tasks were performed. Another resident's documentation inaccurately showed PROM exercises to both legs as not applicable or not done, despite being performed. Interviews confirmed the documentation system's limitations, resulting in inaccurate records.
The facility failed to maintain one washing machine properly and did not monitor the temperatures of washing machines and dryers daily. A leaking washing machine was observed, and the Maintenance Supervisor was unaware of the issue. Interviews with staff emphasized the importance of temperature logs to prevent infection spread, but no logs were maintained.
A facility failed to obtain informed consent from a resident's responsible party before administering psychotropic medications. The resident, with diagnoses including schizophrenia and impaired cognitive skills, was unable to make medical decisions. Despite this, consent was obtained directly from the resident, contrary to facility policy requiring consent from a representative when the resident lacks decision-making capacity.
A resident was subjected to unnecessary physical restraints without proper assessment or a physician's order. Bilateral bolsters were used to prevent the resident from unassisted bed exits and falls, contrary to the facility's policy, which requires trying less restrictive measures first and obtaining a physician's order.
A resident with limited mobility and severe cognitive impairment was found to have a left displaced femoral neck fracture, which the facility failed to report to State Agencies within the required timeframe. Despite the resident's dependency on assistance and the discovery of the fracture through an X-ray, the facility did not complete an investigation into the cause of the injury, as required by their Abuse Prevention policy. This oversight resulted in a delayed investigation and placed the resident at risk for potential abuse or neglect.
A resident with dysphagia was mistakenly served a regular diet instead of the prescribed mechanical soft diet, posing a risk of choking and aspiration. The error was identified by a CNA, and interviews with facility staff confirmed the importance of following the prescribed diet for safety. The facility's policies on therapeutic diets and dysphagia management were not adhered to in this instance.
A resident with severe cognitive impairments and high fall risk sustained a forehead laceration after hitting a bedside drawer during repositioning. Staff interviews revealed awareness of the hazard, but improper execution led to the incident. The facility's policy emphasizes accident prevention, yet the failure to maintain a hazard-free environment resulted in the resident's injury.
The facility failed to meet space requirements for 45 resident rooms, with multi-bed rooms needing at least 80 sq. ft. per resident and single rooms requiring 100 sq. ft. Despite this, residents had enough space for movement and use of mobility aids. The facility's policy requires rooms to meet these standards for privacy and care, but current configurations did not comply.
Inaccurate Documentation of Resident Elopement Attempts
Penalty
Summary
Facility staff failed to accurately document a resident’s elopement history in the clinical record and on multiple Elopement and Wandering Risk Observation/Assessment forms. The resident, admitted with schizoaffective disorder, dementia, and generalized anxiety disorder, had severely impaired cognition per an MDS dated 9/21/2025 and required supervision or touching assistance for ADLs. An SBAR dated 9/14/2025 documented that the resident was observed attempting to jump over a facility fence and was redirected by staff. However, on the Elopement and Wandering Risk Observation/Assessment form completed later that morning, the RN Supervisor recorded in the History of Elopement Attempts section that the resident expressed plans to leave but had not attempted to do so, omitting the documented elopement attempt from earlier that day. A subsequent assessment on 9/29/2025 by the MDS Coordinator again stated the resident planned to leave but had not attempted to do so, despite the prior documented attempt on 9/14/2025. An SBAR dated 11/2/2025 recorded another elopement attempt, describing the resident trying to climb over a fence behind the east building using a bedside table, with a CNA intervening and redirecting the resident. Later that morning, the ADON completed an Elopement and Wandering Risk Observation/Assessment form and again documented that the resident planned to leave but had not attempted to do so, failing to record the elopement attempts on 9/14/2025 and 11/2/2025. On 11/17/2025, the RN Supervisor completed another assessment form and again documented that the resident planned to leave but had not attempted to do so, omitting the two prior attempts. During interview, the DON stated that these Elopement and Wandering Risk Observation/Assessment forms were completed incorrectly and that they provided an inaccurate depiction of the resident’s history, contrary to the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation in the medical record.
Pureed Bread Not Prepared to IDDSI Level 4 Standard
Penalty
Summary
The facility failed to ensure that 26 residents on a pureed diet received pureed textured bread prepared in a form that met their individual needs and IDDSI Level 4 requirements. During tray line observation for lunch, the pureed bread on the steam table appeared lumpy with milk floating on top. In a concurrent interview, Cook2 stated the bread was made by mixing bread with milk and blending it a little, describing it as bread soaked in milk. During a taste test and interview with the Dietary Supervisor and two Registered Dietitians, the pureed bread was found to have a lumpy texture, with small pieces of bread present and residue remaining in the mouth. The Dietary Supervisor stated the consistency was not smooth and that some bread stayed in the mouth, noting it needed more blending. Cook2 later stated the bread was not blended as long as the other pureed foods and that sliced white bread was used. The facility recipe for Pureed (IDDSI Level 4) breads documented that the finished item should be smooth and free of lumps, hold its shape, and should not weep, and the IDDSI guideline stated Level 4 pureed food should have no lumps and no liquid separation.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one of eight sampled residents, Resident 154. Resident 154’s admission record documented diagnoses including Parkinson’s disease and quadriplegia. The communication care plan dated 7/24/2025 documented altered communication, including hearing problems, problems making self understood, no speech, problems understanding others, and dementia. The care plan goal was to ensure Resident 154’s needs would be met daily, and one intervention was to keep the soft touch call light within reach at all times. The MDS dated 10/9/2025 documented Resident 154 was severely impaired in daily decision making and dependent for all ADLs. During an observation on 12/8/2025 at 10:25 a.m., Resident 154’s soft touch call light was hanging over the tube feeding pump at the side of the bed and was not within Resident 154’s reach. During interview, the DON stated the soft touch call light was used for residents who could not traditionally call for help, was very sensitive, and needed to be within resident reach to activate with slight movement. The DON stated the call light hanging over the tube feeding pump defeated the purpose because it would not pick up the resident’s movement. The facility policy titled Answering the Call Light stated that when the resident was in bed, the call light should be within easy reach.
Unnecessary Psychotropic Medication Use and Poor Target Behavior Monitoring
Penalty
Summary
The facility failed to ensure psychotropic medication was not used unnecessarily for one resident with diagnoses including dementia, schizoaffective disorder, and psychosis. The resident had been admitted and later readmitted to the facility, and a psychiatric follow-up note documented limited judgment and insight with orientation to person only. The resident was ordered Seroquel 50 mg at bedtime for schizoaffective disorder, with the order described as being for delusional thoughts and difficulty to redirect. During record review, the resident’s MAR showed behavior monitoring for Seroquel use related to delusional thoughts and difficulty to redirect. The MAR documented episodes on multiple dates in September, October, and November 2025. However, the registered nurse supervisor stated she was not sure what delusional thoughts the resident had, and stated that difficulty redirecting could be caused by dementia-related behavior. She also stated that target behavior should be specific and measurable so the psychiatrist could consider GDR, and that staff should monitor specific target behaviors. The psychiatric nurse practitioner stated he ordered Seroquel for schizophrenia manifested by paranoia, specifically thoughts that people want to harm the resident, and stated he did not know why staff were monitoring delusional thoughts and difficulty to redirect as target behaviors. He stated those were not resident-specific target behaviors and that staff were monitoring the wrong target behaviors. The DON stated target behavior should be specific and measurable to the resident’s diagnosis, and that inaccurate data could delay treatment and result in the resident continuing to receive unnecessary medication. The facility policy stated residents should only receive psychotropic medications when necessary to treat a specifically diagnosed condition documented in the medical record, and that staff should gather and document information to clarify the resident’s behavior, mood, function, medical condition, specific symptoms, and risks.
Inaccurate MDS Coding for Diabetes Treatment and Diagnosis
Penalty
Summary
The facility failed to ensure accurate MDS coding for two residents with diabetes mellitus. For Resident 20, the admission record documented diagnoses of DM, HTN, and dementia, and the order summary showed a physician order for Novolin Flex-pen insulin to be given as a sliding scale before meals and at bedtime for DM. However, the MDS dated [DATE] did not indicate that Resident 20 had an active diagnosis of DM or that he was receiving insulin injections seven days a week. During interview and record review, the MDSC stated Resident 20 had DM and was receiving insulin injections seven days a week, and acknowledged that the MDS was not coded to show DM. The DON also stated the MDS assessment was inaccurate and that coding should be accurate because it reflects the resident’s diagnosis, status, and medical services provided. For Resident 2, the admission record documented DM, and the MDS dated [DATE] documented severe cognitive impairment and that Resident 2 was receiving insulin injections seven days a week. However, the order summary report dated 11/16/2025 to 11/30/2025 showed an order for Jardiance 25 mg oral tablet for DM and no order for insulin injections. During interview and record review, the MDSC stated Resident 2 had DM, had no insulin orders, and was receiving an oral medication for diabetes, and acknowledged that insulin was inaccurately coded on the MDS. The facility policy for Resident Assessments stated that MDS information must consistently reflect progress notes, plans of care, and resident observations and interviews.
Incomplete PTSD Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 10 by not identifying triggers of trauma and not creating individualized interventions related to the resident’s PTSD. Resident 10 was admitted with diagnoses including PTSD, schizoaffective disorder, bipolar disorder, and legal blindness, and had a public guardian. The resident’s H&P documented that Resident 10 was alert and oriented to self, place, and time, and the MDS showed the resident required assistance with eating, bed mobility, hygiene care, showering, dressing, and transfers. During review of the care plan, the focus identified Resident 10 as being at risk for psychosocial/emotional trauma related to PTSD, with a goal that the resident would express feelings of safety and security in the environment. The interventions stated that staff were to help Resident 10 identify triggers that prompt symptoms, but the RNS stated the care plan did not identify what the triggers were and was not specific to Resident 10. The Social Service Initial admission Assessment documented PTSD related to events during homelessness, but did not include a PTSD assessment; the SSD stated the public guardian reported Resident 10 had been assaulted by an ex-boyfriend and was concerned about being out on the street and homeless. The SSD and DON stated that the resident’s trauma should have been assessed and that the care plan should have been specific and implemented as written.
Failure to Update Fall Care Plan After IDT Recommendations and Actual Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 7 after actual fall incidents and after interdisciplinary team (IDT) recommendations were made. Resident 7 was admitted and later readmitted with diagnoses including dementia, schizoaffective disorder, and a history of falls. A psychiatric follow-up note documented limited judgment and insight and orientation to person only. The MDS dated 8/27/2025 documented that Resident 7 required assistance with dressing, showering, hygiene, bed mobility, eating, and transfers. An IDT note dated 8/7/2025 documented that Resident 7 was found sitting on the floor on the left side of the bed on 8/6/2025 with redness on the right upper back, and the IDT recommended initiating a falls care plan, proper footwear, bilateral landing mats, continuing the falling star program, and using a low bed while resting. A later IDT note dated 9/2/2025 documented that Resident 7 was found on the floor sitting on his bottom facing the television in the dining room on 8/30/2025, and the IDT recommended initiating a care plan, continuing the falling star program, placing the resident on a 1:1 sitter for safety, and encouraging wheelchair use when tired. Review of the care plan showed fall-risk interventions such as call light access, activities, assistive device use, medication review, floor mats, low bed, personal items within reach, and proper footwear, but it did not include the falling star program, 1:1 sitter, wheelchair use, or initiation/revision of the care plan after the actual fall incident. The RNS stated these IDT-recommended interventions should have been reflected in the care plan.
Failure to Document Ordered Monitoring
Penalty
Summary
The facility failed to ensure that physician-ordered monitoring was completed and documented as complete for one resident. The resident was admitted with diagnoses including hypertension, dysphagia, type 2 diabetes, and a history of falling. The resident’s MDS documented severely impaired cognition and the need for setup or clean-up assistance or supervision for activities of daily living such as hygiene, toileting, and dressing. The resident’s order summary included multiple monitoring orders, including monitoring for bleeding and other adverse signs related to an antiplatelet medication, monitoring and documenting target behavior episodes each shift due to Depakote, monitoring for signs and symptoms of hyperglycemia and hypoglycemia, monitoring and documenting signs and symptoms of dehydration each shift, monitoring pain level every shift, and monitoring vital signs every shift. Review of the MAR for the night shift showed these monitoring orders were not documented as completed as ordered. During interview and record review, the DON verified the findings and stated that licensed nurses should carry out the monitoring orders as ordered by the physician.
Failure to Provide Ordered Bilateral Floor Mats
Penalty
Summary
The facility failed to ensure Resident 37 had floor mats on both sides of the bed as ordered by the physician. Resident 37 was readmitted on 7/23/2025 with diagnoses including muscle weakness and paranoid schizophrenia. The MDS dated 10/2/2025 documented moderate cognitive impairment and that transfers were not attempted due to medical condition. The care plan revised 10/21/2025 identified the resident as at risk for falls and injuries due to psychoactive drugs, poor safety awareness, impaired mobility, and schizophrenia, and noted the resident was on the fall prevention program. During observations on 12/8/2025, 12/9/2025, and 12/10/2025, Resident 37 was seen in bed with the bed in low position and a floor mat on the right side only, with no floor mat on the left side. The Order Summary Report showed an order dated 9/23/2025 for bilateral floor mats for safety and security. The LVN stated the resident should have had a floor mat on the left side as well and that floor mats are for safety and to prevent injury. The DON reviewed the record and stated the bilateral floor mats should have been implemented right away and that not having them could lead to injury related to a fall.
Failure to Identify PTSD Triggers and Individualize Trauma-Informed Care
Penalty
Summary
The facility failed to identify and intervene in one sampled resident’s history of trauma and triggers related to PTSD, which was documented as a concern in the resident’s care plan. Resident 10 was admitted with diagnoses including PTSD, schizoaffective disorder, bipolar disorder, and legal blindness, and had a public guardian. The admission record and H&P documented the resident was alert and oriented to self, place, and time, and the MDS showed the resident required assistance with eating, bed mobility, hygiene care, showering, dressing, and transfers. During review of the care plan, the focus identified the resident as being at risk for psychosocial/emotional trauma related to PTSD and stated staff would help identify triggers that prompt symptoms, but no specific triggers were documented. The RNS stated the care plan did not indicate what the resident’s triggers were and that the interventions were not individualized without identifying what might trigger re-traumatization. The RNS stated it was important to identify triggers and implement individualized interventions to prevent re-traumatization. The Social Service Initial admission assessment documented PTSD related to homelessness, but did not include a PTSD assessment. The SSD stated the public guardian reported the resident had been assaulted by an ex-boyfriend while homeless and that the resident was concerned about being out on the street and homeless. The SSD stated staff should have assessed and identified PTSD triggers and the severity of possible re-traumatization, and the DON stated it was important to identify PTSD triggers to prevent re-traumatization and provide appropriate care. A behavioral health progress note also documented that the resident met criteria for PTSD, but there was no documentation of PTSD triggers or severity.
Resident Room Size Requirements Not Met
Penalty
Summary
The facility failed to ensure that 17 of 91 resident rooms met the required square footage standards of at least 80 square feet per resident in multi-bed rooms and 100 square feet for single resident rooms. A review of the facility's Client Accommodations Analysis form, provided on 12/9/2025 and revised 12/11/2025, showed that multiple rooms on the East Unit and another unit measured less than 80 square feet per resident in multi-bed rooms, including rooms T1, T3, T8, T10, T12, T14, T15, T17, T18, and T20 on the East Unit, and rooms T21, T23, T27, T29, T30, T32, and T34 on the other unit. These rooms ranged from 298.75 sq. ft. to 360.5 sq. ft. and housed 4 or 5 residents each. During observations from 12/8/2025 through 12/11/2025, residents in these rooms had enough space to move freely inside the rooms. Each room had beds and side tables with drawers, and there was adequate room for the operation and use of wheelchairs, walkers, or canes. During interview on 12/11/2025 at 12:25 p.m., the Administrator stated the facility was aware that 17 rooms did not meet the 80 square foot requirement for multi-resident rooms and stated it was important to ensure each resident had enough space and staff were able to provide resident care with enough room to move around. The facility's policy titled Bedrooms, revised 1/2025, stated bedrooms accommodate no more than two residents at a time, bedrooms measure at least 80 square feet per resident in double rooms, and each room is designed to provide full visual privacy and adequate nursing care.
Failure to Report Fall and Initiate Neurological Assessment
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to report an unwitnessed fall involving a resident with diagnoses including dementia, Parkinson's Disease, and epilepsy. After discovering the resident on the floor, CNA 1 assisted the resident back into bed without notifying a licensed nurse or supervisor, as required by the facility's job description for CNAs. The resident later informed a Licensed Vocational Nurse (LVN) about the fall, which led to delayed awareness and response by facility leadership. The facility did not have a policy or procedure outlining the steps to take when a resident is found on the floor. Following the delayed report of the fall, the facility failed to initiate a neurological assessment as required by their own policy. The resident's neurological status was not evaluated after the fall was reported, and no assessment was performed prior to the resident's transfer to a General Acute Care Hospital for further evaluation and treatment. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that a neurological assessment should have been conducted after learning of the fall, but this was not done.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of paranoid schizophrenia and generalized anxiety disorder physically assaulted his roommate, who had severe cognitive impairment and multiple psychiatric and medical diagnoses. The incident took place in a shared restroom, where the assaulted resident entered while the other was using the facility. The aggressor demanded the other resident leave, but when he did not comply and approached, the aggressor made physical contact, resulting in the victim being punched in the face and pushed to the floor. The assaulted resident sustained significant injuries, including a left periorbital discoloration, a nasal bridge discoloration, a skin tear on the left eyebrow, and a skin tear on the left dorsal fifth digit. Medical evaluation at a general acute care hospital confirmed a mildly depressed nasal bone fracture and a left periorbital hematoma. The incident was witnessed by a CNA who responded immediately, and emergency services were called to transfer the injured resident for further evaluation and treatment. Interviews with facility leadership confirmed that the altercation was considered physical abuse, and both the Assistant Director of Nursing and Director of Nursing acknowledged the residents' right to be free from abuse. The facility's policy also states a commitment to protect residents from abuse, including abuse from other residents. The report documents that the facility failed to protect the resident's right to be free from physical abuse, resulting in physical harm.
Failure to Provide Required Supervision Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with a history of wandering from physical abuse by not providing required 1:1 supervision as outlined in the resident's care plan. The resident, who had diagnoses including paranoid schizophrenia, dementia, and cognitive communication deficits, was known to wander into other residents' rooms and had been identified as at risk for wandering. Despite this, staff did not consistently implement 1:1 monitoring, and the resident was able to enter another resident's room unsupervised. Another resident, who had a documented history of aggressive behavior, schizoaffective disorder, antisocial personality, and amnestic disorder, was residing in the same secured unit. This resident had previously exhibited poor impulse control and had a history of physically assaulting peers. On the day of the incident, staff were not actively monitoring the hallways, and both residents were only being checked every two hours, rather than being under continuous observation as required for the wandering resident. As a result of these lapses, the wandering resident entered the aggressive resident's room, leading to a physical altercation. The aggressive resident struck the wandering resident in the face, causing injuries including a right cheek abrasion, orbital discoloration, nosebleed, and a scalp hematoma. The incident was unwitnessed, and staff only became aware after hearing yelling. Interviews with staff confirmed that the required 1:1 supervision was not in place at the time of the incident, and that the facility's policy to protect residents from abuse was not followed.
Failure to Prevent Elopement of High-Risk Residents Due to Inadequate Supervision and Lapses in Security Procedures
Penalty
Summary
Two residents, both assessed as high risk for elopement due to cognitive impairments such as dementia and schizophrenia, were able to leave the facility unsupervised and without staff awareness. Both residents had documented care plans indicating their risk for wandering and required supervision, including monitoring their location every two hours and implementing diversional interventions. Despite these documented needs, staff failed to adequately monitor the residents' whereabouts, and their absence went unnoticed for an extended period. On the day of the incident, a staff member (CNA) observed two women near a locked door leading to the facility's lobby and, believing them to be visitors, signaled for the receptionist to unlock the door. The receptionist, unfamiliar with the residents and not recognizing them as such, allowed them to enter the lobby and subsequently exit through the facility's front entrance. There was no process in place to verify the identity of individuals leaving the facility, and the receptionist did not check for visitor badges or confirm their status before permitting exit. Other staff members later noticed the residents' lunch trays were untouched but did not immediately investigate their whereabouts, assuming they were elsewhere in the facility. The residents were missing for approximately 27 hours before being located by a family member about 20 miles from the facility. Both were subsequently transported to a hospital for evaluation and treatment, with one admitted for altered mental status and the other for a urinary tract infection. Interviews with staff revealed a lack of familiarity with residents, absence of a visitor check-out process, and failure to follow care plan interventions for monitoring high-risk residents, all of which contributed to the residents' unsupervised exit and delayed discovery.
Failure to Provide Elopement Prevention Training to Staff
Penalty
Summary
The facility failed to provide required training on resident elopement prevention for all new and existing staff members, as evidenced by a review of employee files for eight sampled staff members, including Certified Nursing Assistants and a Restorative Nursing Assistant. There was no documented evidence that these employees received training related to resident elopement, despite the facility's own assessment indicating that such training was necessary for staff to provide appropriate care and support for residents at risk of elopement or wandering. As a result of this lack of training, two residents were able to move from a locked area into the facility's lobby and subsequently exit through the front door without supervision or authorization. Interviews with the Director of Staff Development revealed that while new hire training included a response protocol for missing residents (Code Black), it did not cover preventive interventions or how to distinguish residents from visitors. The Director of Nursing believed that elopement training was ongoing, but there was no evidence to support this, and staff had not received the required education upon hire or annually.
Failure to Provide Timely Written Bed Hold Notices After Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to the responsible parties of two residents within 24 hours of their transfer to a general acute care hospital, as required by facility policy and federal regulations. Both residents had cognitive impairments and required varying levels of assistance with activities of daily living. Documentation showed that while the responsible parties were verbally informed of the bed hold policy at the time of transfer and had previously received information upon admission, there was no evidence that a written notice was created or provided within the required timeframe following the hospital transfer. Record reviews and interviews confirmed that the Social Services Director notified the responsible parties verbally but could not produce documentation of a written bed hold notice for either resident after their transfer. The facility's policy specifies that written information regarding bed hold policies must be provided at the time of transfer or within 24 hours if the transfer is an emergency. The absence of this documentation resulted in an incomplete record regarding the residents' bed hold status and notification to their responsible parties.
Missed Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to complete neurological assessments according to protocol for a resident who experienced an unwitnessed fall and sustained a head injury. The resident, who had diagnoses including Parkinson's Disease, muscle weakness, and severely impaired cognition, required neurological checks as ordered by the physician following the incident. The protocol specified a detailed schedule for neurological assessments, but review of the Neurological Assessment Flowsheet revealed that 11 assessments were missed over several days. Documentation showed that the assessments were not performed at the required intervals, and some scheduled checks were omitted entirely. During interviews and record reviews, the LVN responsible for the assessments was unable to explain the discrepancies in documentation and timing. The DON confirmed that the neurological assessment schedule was not followed as outlined in the facility's policy and the physician's orders. The facility's policy emphasized the importance of conducting neurological checks as frequently as ordered to monitor for changes indicative of neurological injury. This failure resulted in incomplete and incorrect neurological assessments for the resident after the fall.
Failure to Document Nursing Fall Assessment After Resident Fall and Injury
Penalty
Summary
A resident with diagnoses including Parkinson's Disease and muscle weakness, and who had severely impaired cognition and required partial to moderate assistance with activities of daily living, experienced an unwitnessed fall in his room resulting in a cut to his left eyebrow. The resident's physician was notified, and staff were instructed to monitor the resident and conduct neuro checks following the incident. Upon review of the resident's medical record, there was no documented evidence that a Nursing Fall Assessment was completed after the fall and injury. The Director of Nursing confirmed that a licensed nurse should have completed a Nursing Fall Assessment to guide staff in implementing appropriate interventions. The facility's policy indicated that staff are to identify interventions related to the resident's specific risks and causes to prevent falls and minimize complications, but this was not documented in this case.
Failure to Obtain Proper Informed Consent Prior to Administration of Psychotropic Medications
Penalty
Summary
Licensed nurses at the facility failed to ensure that informed consent was properly obtained from residents or their responsible parties prior to administering antipsychotic and psychotropic medications. In several cases, consents were either obtained after the medications had already been administered or were obtained by licensed nurses rather than the prescribing provider, contrary to facility policy. For example, one resident with dementia and schizophrenia, who lacked capacity to make medical decisions, received multiple psychotropic medications, including Ativan, Divalproex Sodium, and Zyprexa, before the responsible party was informed or consented. The responsible party later stated they were not made aware of the medications being administered. Another resident with vascular dementia and schizoaffective disorder, who was determined to have the capacity to make medical decisions, was administered Prozac and Seroquel before informed consent was obtained. Documentation showed that the medications were given prior to the date the consent was signed, and the Assistant Director of Nursing confirmed that consent should have been obtained beforehand. Similarly, a third resident with dementia and schizophrenia, who was not capable of making medical decisions, received Divalproex Sodium and Quetiapine Fumarate before any informed consent was documented. In one instance, the provider's signature on the consent form was dated well after the medication had already been administered. Facility policy required that the prescribing clinician obtain and document informed consent from the resident or their representative prior to the administration of psychotropic medications, including a review of non-pharmacological alternatives, risks, benefits, and the right to refuse. However, the review found that these procedures were not consistently followed, with licensed nurses sometimes obtaining consent instead of the provider, and medications being administered before consent was documented. These actions resulted in residents receiving antipsychotic and psychotropic medications without being fully informed or having the opportunity to consent or refuse, as required by facility policy.
Failure to Follow Physician Orders and Assess Skin Conditions
Penalty
Summary
The facility failed to carry out a physician's order for a follow-up appointment with an orthopedic specialist for a resident who had sustained a fractured radius and was placed in a soft cast. The resident was readmitted to the facility after a fall and had an order to follow up with the orthopedic specialist in two weeks. However, this order was not reentered upon the resident's readmission from the hospital, leading to a delay in the follow-up appointment, which was eventually scheduled more than six weeks later. The delay in care resulted in the resident being unable to use her right hand, affecting her ability to perform daily activities. Additionally, the facility failed to assess another resident's skin condition according to standards of practice. The resident had a swollen left foot with visible scratches, which were not detected by the staff during routine assessments. The resident required assistance with activities of daily living, and the changes in her skin condition were not observed by the CNAs or the treatment nurse. This lack of assessment and documentation of skin changes could lead to serious health consequences for the resident. Interviews with facility staff revealed that there was a breakdown in communication and responsibility regarding the scheduling of appointments and the assessment of residents' conditions. The nursing team was responsible for scheduling appointments, but the order for the orthopedic follow-up was not reentered, and the social services team was unaware of the need for transportation arrangements. Similarly, the nursing staff failed to properly assess and document the skin condition of the second resident, indicating a lapse in following the facility's policies and procedures for resident care.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for three residents. For one resident, Lurasidone was prescribed without a justifiable diagnosis, as the resident did not exhibit behaviors that warranted such medication. The facility's pharmacy consultant and psychiatrist acknowledged that the medication was inappropriate, and the resident's care plan did not align with the observed behaviors, which were minimal and did not justify the use of Lurasidone. Another resident was prescribed Seroquel and Trazodone, but the facility failed to document daily monitoring for side effects. The Licensed Vocational Nurse (LVN) admitted that side effect monitoring was only done on an as-needed basis, which was insufficient. The Psychiatrist Medical Doctor (PMD) emphasized the importance of monitoring for side effects every shift, but the facility had changed its monitoring policy due to staff complaints about documentation time. For the third resident, Risperdal was ordered for schizophrenia, but the resident did not have a diagnosis of schizophrenia. The LVN and Director of Nursing (DON) confirmed that the order was input incorrectly, and the medication was intended for unspecified psychosis. The facility's policy required that antipsychotic medications be used only for specific conditions, but this was not adhered to, leading to inappropriate medication use.
Failure to Label and Date Food Items in Storage
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the dry storage area, as evidenced by an unopened box of croissants that was not labeled with a use-by date. During an observation, a croissant within the box was found to have a dime-sized greenish fuzzy spot, indicating spoilage. The dietary director (DD) confirmed that the box was not dated and acknowledged that the croissants were only good for seven days. The DD also stated that all food stored in the facility kitchen needed to be labeled and dated to prevent spoilage and ensure food safety. The facility's policy and procedure on labeling and dating foods, dated 2023, requires all food items in the storeroom, refrigerator, and freezer to be labeled and dated. Additionally, the 2022 U.S. Food and Drug Administration (FDA) food code mandates that unsafe, adulterated, or contaminated food must be discarded or reconditioned according to an approved procedure. The failure to adhere to these guidelines resulted in the potential for pathogen exposure and placed residents at risk for developing foodborne illnesses.
Inaccurate Documentation of RNA Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aide (RNA) services were accurately documented for several residents, leading to discrepancies between the RNA documentation and the prescribed orders. For one resident, the RNA flowsheet did not match the physical therapy discharge recommendations and physician's orders regarding the application of splints. The Director of Rehabilitation confirmed that the RNA task and frequency did not align with the therapy recommendations, which could result in inappropriate provision of services. Another resident's RNA flowsheet had missing documentation for several dates, indicating that RNA services were not documented as provided. The RNA responsible admitted that services were provided but not documented, which contradicts the facility's policy that states if services are not documented, they are considered not provided. This lack of documentation could lead to confusion and inappropriate care provision. Additionally, for another resident, the RNA task was not resolved when services were discontinued, leading to an inaccurate reflection of services provided. The Director of Rehabilitation and the Director of Staff Development confirmed that the RNA task remained active even after the resident was transferred to the hospital, which should have been resolved to prevent confusion. The facility's policy requires accurate documentation to ensure appropriate care and services, which was not adhered to in these cases.
Inadequate Hand Hygiene by LVN During Meal Service
Penalty
Summary
The facility failed to implement proper infection control measures as observed during a lunch service in the dining room. A Licensed Vocational Nurse (LVN) was seen checking residents' lunch trays without performing hand hygiene after adjusting her mask and touching her hair. The LVN continued to handle food items and juice cups without sanitizing her hands, despite having touched her face and hair multiple times. This behavior was acknowledged by the LVN during an interview, where she admitted that she should have washed or sanitized her hands to prevent cross-contamination and the spread of infection. Interviews with the Infection Control Nurse (ICN) and the Director of Nursing (DON) confirmed that the facility's policy requires staff to perform hand hygiene before, after, and between tasks to prevent cross-contamination. The facility's policies on hand hygiene and infection control emphasize the importance of handwashing as the primary means to prevent healthcare-associated infections. The failure to adhere to these policies by the LVN had the potential to compromise infection control measures, posing a risk of infection spread among residents, staff, and visitors.
Failure to Implement Care Plan Intervention for Anticoagulant Therapy
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who was on anticoagulant therapy. The resident, who had a history of a displaced spiral fracture of the left femur, atherosclerotic disease of the coronary artery, and heart failure, was supposed to wear a medical alert bracelet indicating their anticoagulant therapy status. However, during an observation and interview, the resident stated they had never received such a bracelet, and it was confirmed that they were not wearing one. Licensed Vocational Nurse (LVN) 3 reviewed the resident's care plan and confirmed that it included the intervention for wearing a med alert bracelet. Despite this, the intervention was not implemented, as observed during a follow-up interview and record review. The Director of Nursing acknowledged that all care plan interventions should be followed to ensure residents receive appropriate care and services. The facility's nurse job description also emphasized the importance of reviewing care plans daily to ensure proper care is administered.
Failure to Lock Wheelchair Brakes During Resident Transfer
Penalty
Summary
The facility failed to ensure that a Restorative Nursing Aide (RNA) locked both wheelchair brakes before assisting a resident, identified as Resident 156, into a standing position. Resident 156, who was admitted with diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease, was at moderate risk for falls. During an observation, RNA 1 assisted Resident 156 with walking exercises using a front-wheeled walker. However, when Resident 156 sat down to rest and was later assisted into standing, RNA 1 only locked the right wheelchair brake, leaving the left brake unlocked. This oversight was acknowledged by RNA 1, who admitted that both brakes should have been locked to ensure safety. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that both wheelchair brakes must be locked prior to standing a resident to prevent falls and accidents. The facility's policy and procedure on transfers also emphasized the importance of locking wheelchair brakes to provide safety for residents and staff. The failure to lock both brakes placed Resident 156 at risk for falls and injury, highlighting a deficiency in the facility's adherence to safety protocols.
Improper Needle Disposal and Inaccurate Drug Records
Penalty
Summary
The facility failed to properly dispose of needles and maintain accurate drug records, which could compromise resident and staff safety. During an observation and interview, it was found that four Enoxaparin injections with needles were improperly disposed of in a regular trash bin instead of a designated sharps container. The Licensed Vocational Nurse (LVN) acknowledged this error, and the Director of Nursing (DON) confirmed that such disposal practices could lead to injuries. The facility's policies, dated 2001 and revised in 2018, clearly state that contaminated sharps should be discarded immediately into designated containers. Additionally, the facility did not maintain accurate drug records for controlled substances. During a review, it was discovered that the narcotic sheets for acetaminophen-codeine and Tramadol tablets lacked proper documentation, including the DON's signature, date, and a witness signature. The DON acknowledged the importance of proper documentation to prevent medication misplacement or diversion. The facility's policy, revised in 2018, requires accountability records for controlled substances to include signatures and dates when medications are destroyed.
Failure to Label Medication Open Dates
Penalty
Summary
The facility failed to properly label a tuberculosis (TB) purified protein derivative (PPD) vial and a Rybelsus bottle with the open dates, as observed during a survey. During an observation and interview with an LVN in the Villa unit, a TB PPD vial was found without an open date. The LVN acknowledged that the vial should have been labeled with the open date. Similarly, in the Terrace unit, another LVN identified a Rybelsus bottle that lacked an open date, stating that accurate labeling is necessary to ensure medications are used before they expire. The Director of Nursing (DON) confirmed that medications should have the open date labeled directly on the medication bottle to ensure they are used within the appropriate period. The DON explained that failure to label the open date can lead to compromised medication efficacy, potentially resulting in inaccurate TB test readings and ineffective blood sugar control for residents. The facility's policy and procedure on vials and ampules of injectable medications, revised in January 2018, indicated the importance of recording the open date and triggered expiration date on multidose vials.
Deficiency in Room Size and Mobility Accommodation
Penalty
Summary
The facility failed to ensure that 45 out of 95 resident rooms met the required space standards of 80 square feet per resident in multi-bed rooms and 100 square feet for single resident rooms. Specifically, 43 rooms in the Palm Unit and two rooms in the Palm East Unit were found to be below these standards. This deficiency was identified during a review of the facility's Client Accommodations Analysis form, which revealed that the rooms in question were significantly smaller than required, potentially hindering effective evacuation during emergencies. Additionally, the facility failed to accommodate the needs of a resident who required a wheelchair for mobility. The resident, who had a history of generalized muscle weakness and acute osteomyelitis, was observed struggling to maneuver in their room due to the narrow space between beds, which was less than the width of the wheelchair. This obstruction was confirmed by both the Assistant Director of Nursing and the Director of Nursing, who acknowledged that the resident's mobility and independence were compromised, and that the situation could impede evacuation in an emergency.
Failure to Protect Residents from Abuse in Smoking Patio Area
Penalty
Summary
The facility failed to protect residents from abuse in the smoking patio area, resulting in an altercation where one resident hit another on the nose. This incident led to the injured resident sustaining a nosebleed and requiring hospital evaluation and treatment. The deficiency was identified through observation, interviews, and record reviews, highlighting a lack of adequate supervision in the smoking patio area. Resident 11, who has severe cognitive impairment and requires supervision for self-care and mobility, was involved in the altercation. The resident was admitted with diagnoses including schizophrenia, major depressive disorder, anxiety disorder, and insomnia. During the incident, Resident 11 was in a wheelchair and sustained a hematoma on the nose and an abrasion on the hand. The resident was sent to the hospital for further evaluation due to concerns about potential intracranial bleeding. Resident 54, who has intact cognitive ability but has been noted to have agitation and paranoia, was the other party involved in the altercation. The resident struck Resident 11 on the nose after accusing them of taking money. Despite the presence of staff in the vicinity, the altercation occurred quickly, and the staff did not witness the incident directly. The facility's policy on abuse prevention emphasizes the need for adequate staffing and oversight to prevent such incidents, but this was not effectively implemented in this case.
Failure to Prevent Significant Medication Errors in Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident diagnosed with atrial fibrillation and receiving Warfarin was free from significant medication errors. The resident's Warfarin was not administered as ordered by the physician's Nurse Practitioner, leading to multiple instances of duplicate therapy. Specifically, the resident received overlapping doses of Warfarin on several occasions, which included doses that should have been discontinued. This resulted in the resident receiving excessive amounts of Warfarin, contrary to the prescribed regimen. The licensed nurses did not adequately monitor medication administration times and critical laboratory values, which are essential to prevent and detect medication errors. Despite receiving critical INR results indicating dangerously high levels, the facility staff failed to follow up with the physician when there was no response to the reported lab results. This lack of follow-up and communication with the physician contributed to the resident's condition worsening, as the INR levels remained critically high without appropriate intervention. As a result of these failures, the resident was transferred to a General Acute Hospital, where they were diagnosed with a subdural hematoma. The resident required intubation and administration of Andexxa to reverse the effects of the anticoagulant medication. The facility's inability to manage the resident's medication regimen and monitor critical lab values led to a serious adverse event, highlighting significant deficiencies in medication management and communication protocols.
Removal Plan
- A comprehensive three-way audit of 13 medication carts was initiated. This audit was conducted collaboratively by the Pharmacy and facility staff to ensure medications were administered correctly based on supply availability, medications availability, match of the medication blister pack/medication container to the physician orders, proper documentation, and medications that were revised previous orders were discontinued. Any issues identified were immediately corrected by the auditing nurse and communicated to the DON for review.
- One on one education was provided to the Consulting Pharmacist by the Pharmacy Regional Director of Operations. The session focused on the CP's role in conducting monthly drug regimen reviews for residents receiving anticoagulant medications. The key topics included the importance of monitoring medication administration times, critical lab values, and the pharmacist's collaborative role as part of the Interdisciplinary Team.
- The Pharmacy Consultant conducted a Drug Regimen Review for 23 current residents who were receiving anticoagulant medication. Recommendations were communicated to the resident's physicians by the facility nursing staff and addressed accordingly.
- A facility wide audit was conducted by the facility nursing staff for all residents utilizing the Anticoagulant Audit tool to ensure current residents receiving anticoagulant medication had orders to monitor for signs and symptoms of bleeding every shift. The audit identified all current residents receiving anticoagulant therapy had routine monitoring of anticoagulant side effects.
- A facility wide audit was conducted by the nursing staff to ensure proper administration of anticoagulant medications utilizing the Anticoagulant Audit tool. The audit confirmed that all current residents who were prescribed anticoagulant medications were accurately identified, and no other residents were receiving those medications inappropriately.
- The Assistant Regional Director of Clinical Services conducted a thorough chart review for 23 residents currently receiving anticoagulant medications. The review was undertaken to ensure the accuracy of medication orders, accurate monitoring of side effects with recommended frequency and to verify there were no instances of incorrect duplicate medications.
- An in-service was initiated to licensed nurses by the DON focusing on the Anticoagulation Therapy Clinical Protocol including Warfarin's dosage, side-effects, significance of laboratory tests, and International Normalized Ratio therapeutic levels.
- The DON initiated an in-service for licensed nurses to address key medication management objectives. The training aimed to ensure medications were administered correctly based on the available supply, availability of medication was verified, the medication blister packs or containers matched physician orders, proper documentation was maintained, and any medication changes were accompanied by the discontinuation of previous orders. Nurses who were unable to attend the session were instructed to report to the DON/designee during their next scheduled shift to receive the in-service.
- The DON initiated an in-service for licensed nurses focused on ensuring the accuracy of medication orders, proper monitoring of side effects at the recommended frequency, and verifying the absence of incorrect or duplicate medications. Nurses unable to attend the in-service were instructed to report to the DON/designee during their next scheduled shift to receive the in-service.
- An in-service was provided initiated to licensed nurses by DON regarding policy and procedure on Medication Administration to ensure medications are administered per physician's order, orders are clarified if not available/not matching with supply at hand, and medications that were changed and have ongoing previous orders are clarified and discontinued.
- The Medical Director was notified of the IJ by the ADM.
- An Ad Hoc Quality Assessment and Assurance Committee meeting was scheduled to discuss the IJRP.
Failure to Conduct Comprehensive Medication Regimen Review for Warfarin
Penalty
Summary
The facility failed to ensure that a comprehensive Medication Regimen Review (MRR) was conducted by the Consulting Pharmacist (CP) for a resident, specifically regarding the administration of Warfarin and the monitoring of related laboratory results. The resident, who was admitted with a diagnosis of atrial fibrillation, was prescribed Warfarin with varying dosages throughout November 2024. However, the MRRs for November and December 2024 did not include any recommendations from the CP concerning the Warfarin administration or the resident's lab results, which are crucial for monitoring the medication's effects. Interviews with the Pharmacy Regional Director and the CP revealed that Warfarin requires close monitoring due to its narrow therapeutic range and potential for adverse side effects, such as abnormal bleeding. Despite this, the CP did not make recommendations because he was unaware of the physician's dosing protocol. The facility's policy requires the CP to perform a comprehensive review of each resident's medication regimen and clinical record monthly, including collaboration with the interdisciplinary team and reporting any irregularities. The failure to adhere to these guidelines resulted in the administration of unnecessary doses of Warfarin, placing the resident at risk for adverse side effects.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding critical laboratory results for a resident diagnosed with atrial fibrillation and on anticoagulant therapy. The resident's INR levels were critically high on two separate occasions, indicating a significant risk for bleeding. Despite the facility's policy requiring critical lab values to be reported to a physician within four hours, and further action if no response was received, the staff did not follow up with the physician or contact the Medical Director after the initial notification. The resident, who was severely cognitively impaired and dependent on staff for daily activities, had an INR level of 6.19 and 5.83 on two different dates, both flagged as critical. The nursing staff documented the transmission of these results to the physician but failed to ensure a response or further action as per the facility's policy. Interviews with staff confirmed the lack of follow-up, highlighting a gap in communication and adherence to procedures designed to manage critical health information.
Failure to Clarify Aspirin Dosage Order
Penalty
Summary
The facility failed to clarify a physician's order for aspirin (ASA) for a resident, resulting in a discrepancy that persisted for three months. The physician had ordered ASA, 81 mg by mouth, but the facility documented it as ASA 1 mg by mouth. This discrepancy was not clarified by the licensed nursing staff, leading to potential confusion and miscommunication regarding the resident's care needs. The resident involved had a history of cerebral infarction and was moderately cognitively impaired, requiring ASA for cerebrovascular accident prevention. The issue was identified during a review of the resident's records, including the Admission Record, Minimum Data Set, Order Summary Report, and Medication Administration Record. Interviews with the LVN and the Director of Nursing revealed that the licensed nurses were expected to verify medication orders and clarify any discrepancies with the physician. However, this process was not followed, as evidenced by the continued administration of the incorrect dosage. The facility's policy and procedure for administering medications required staff to verify the right medication, dosage, and other factors before administration, which was not adhered to in this case.
Deficiency in Pain Management Documentation
Penalty
Summary
The facility failed to ensure proper documentation and indication for the use of pain medication for a resident, leading to a deficiency in pain management. Resident 5, who was admitted with diagnoses including osteomyelitis and dementia, had physician's orders for acetaminophen and ibuprofen for pain management. However, the orders did not specify the indication for use, and the medication administration record (MAR) lacked documentation of the location of the resident's pain or the effectiveness of the medication administered. This resulted in the inability to determine the specific reason for the pain medication, the location of the pain, and whether the medication was effective. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that there was a lack of awareness regarding the need to document the type and location of pain for medication administration. The facility's policies and procedures on pain assessment and medication therapy emphasized the importance of identifying pain characteristics and ensuring a clear indication for medication use. However, these guidelines were not followed, leading to potential issues with continuity of care and effective pain management for the resident.
Inaccurate Documentation of Medication Administration and Pain Assessment
Penalty
Summary
The facility failed to accurately document medication administration for one resident, leading to inaccurate records of care following a fall with injury. The resident, who had a history of osteomyelitis and dementia, was moderately impaired in cognition and required assistance with daily activities. On the day of the incident, the resident was found on the floor after a fall, and a nurse administered acetaminophen for head pain but failed to document the location of the pain or the effectiveness of the medication. The resident's Medication Administration Record (MAR) showed discrepancies in the documentation of pain medication administration. The MAR indicated that both acetaminophen and ibuprofen were given for different pain levels, but the location of the pain was not documented. Additionally, the nurse documented the administration of acetaminophen later in the evening, which did not align with the time it was reportedly given. The Director of Nursing noted that the pain assessment should have included details such as the location and type of pain, which were missing from the records. The facility's policies and procedures required thorough documentation of services provided, including medication administration and pain assessments. However, the nurse failed to document the resident's injuries accurately after the fall, as the resident sustained knee abrasions that were not initially recorded. This lack of documentation could hinder communication among the interdisciplinary team and affect the continuity of care for the resident.
Failure to Supervise Legally Blind Resident During Mealtime
Penalty
Summary
The facility failed to ensure proper supervision during mealtime for a resident diagnosed with legal blindness, resulting in feelings of neglect and indignity. The resident, who also had diagnoses of diabetes mellitus, open-angle glaucoma, and bipolar disorder, required supervision with one-person assistance during meals as indicated in her care plan. Despite this requirement, the resident reported that nursing staff did not consistently provide the necessary supervision, leading to food spilling on her clothing and surroundings, which negatively impacted her psychosocial and emotional well-being. Observations confirmed that the resident was left unsupervised during mealtime, with food particles and salad dressing observed on her face, clothing, and the floor. Nursing staff, including CNAs, were seen passing by without offering assistance, and one CNA acknowledged the resident but did not provide help. The CNA later admitted that she did not find the situation concerning and assumed it was normal for the resident to spill food due to her blindness, despite acknowledging her responsibility to assist the resident. Interviews with facility staff, including an LVN and the Director of Nursing Services, highlighted a lack of adherence to the care plan and facility policies. The LVN emphasized the importance of conducting room rounds to identify and attend to residents' needs, while the Director of Nursing Services reiterated the expectation that all residents should be treated with dignity and respect, with appropriate assistance provided for activities of daily living. The facility's policies on ADLs and dignity were reviewed, underscoring the requirement for residents to be cared for in a manner that promotes their well-being and self-esteem.
Facility Fails to Readmit Resident After Hospitalization Exceeds Bed-Hold Policy
Penalty
Summary
The facility failed to readmit a resident after hospitalization, which exceeded the seven-day bed-hold policy. The resident, who had been admitted to the facility with diagnoses including dementia, metabolic encephalopathy, depression, and anxiety disorder, was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment due to behavioral symptoms such as agitation, aggression, and psychosis. The resident was ready to return to the facility after treatment, but the facility denied readmission, resulting in the resident remaining at the GACH unnecessarily for an additional six days. The facility's policy and procedure indicated that residents should be permitted to return following hospitalization or therapeutic leave, regardless of payer source, and should be given priority in readmission. However, the facility's staff, including the registered nurse supervisor and the administrator, stated that they could not readmit the resident as the seven-day bed-hold had been exceeded, and the resident would be considered a new admission. This decision was influenced by the facility's status as a special-focus-facility under CMS, which they believed would not reimburse for services rendered to the resident if readmitted as a new admission. The facility's actions were contrary to their own policy, which allowed for the return of residents after the bed-hold period had expired. The facility's marketer communicated to the GACH that the resident could not be accepted back due to the expiration of the bed-hold. This resulted in the resident being displaced from the facility, which was considered their home, and placed at risk for confusion, disorientation, and psychosocial harm due to the unnecessary extended stay at the GACH.
Incomplete Advance Directives and POLST Documentation
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) were properly discussed, documented, and completed for three residents. Resident 151, who was diagnosed with cerebral infarction, schizoaffective disorder, end-stage renal disease, major depressive disorder, and alcohol dependence, was found to lack the capacity to make decisions. Despite this, Resident 151's POLST was incomplete, missing the physician's license number and preparer's information, and was signed by the resident who was deemed incapable of understanding or signing the document. This oversight meant that the resident could be treated against their wishes during an emergency. Resident 191, with diagnoses including Parkinson's disease, epilepsy, and paranoid schizophrenia, had fluctuating decision-making capacity. The POLST for Resident 191 was also incomplete, lacking the physician's license number and phone number, and was based on verbal consent from a responsible party without the required two witness signatures. The facility's policy indicated that without a completed POLST, the resident would be treated as a full code, potentially against their DNR wishes. Resident 170, diagnosed with epilepsy, schizophrenia, major depressive disorder, and cognitive communication deficit, was found to have impaired insight and judgment. The POLST for Resident 170 was outdated and incomplete, with missing physician information, and there was no evidence that an AD was offered or documented. The facility's failure to ensure complete and accurate documentation of ADs and POLSTs for these residents posed a risk of not honoring their healthcare wishes during emergencies.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Minimum Data Set (MDS) for two residents, leading to potential negative impacts on their care plans. For Resident 194, the MDS inaccurately indicated the presence of an indwelling catheter, despite it being removed and discontinued in the previous year. This error was confirmed during an interview with the Interim Minimum Data Set Coordinator (IMDSC), who acknowledged the incorrect coding and its potential to negatively affect the resident's care plan. For Resident 180, the MDS inaccurately classified a skin condition as a stage 2 pressure injury, even though it had been reclassified by a wound care specialist as a self-inflicted skin ulcer. This misclassification was identified during a review of the resident's progress notes and confirmed by the IMDSC, who noted that the incorrect coding could lead to inappropriate treatment for the resident. The facility's policy and procedure documents emphasize the importance of accurate MDS assessments, which should reflect information from progress notes, care plans, and resident observations. The Director of Nursing (DON) also highlighted the necessity of correct MDS coding to ensure appropriate care and treatment for residents. These deficiencies in documentation could potentially impact the delivery of necessary services and care for the affected residents.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for four residents, leading to deficiencies in grooming and oral hygiene. Residents 165, 125, and 101 were observed with long, untrimmed fingernails with a black substance underneath, indicating a lack of proper nail care. These residents were dependent on staff for personal hygiene due to cognitive impairments and physical limitations, as documented in their Minimum Data Sets (MDS) and medical records. Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) acknowledged the condition of the residents' fingernails and confirmed that it was the responsibility of CNAs to maintain residents' nail hygiene. Resident 62 was found with poor oral hygiene, including dry, cracked lips and a mouth covered with brown/yellow substances. This resident required total assistance with oral hygiene due to cognitive impairments and physical dependency, as noted in the MDS. A CNA confirmed that Resident 62 had not received oral care for at least two days, which is contrary to the facility's policy that mandates daily oral care for residents. The facility's policies and procedures for Activities of Daily Living (ADL), fingernail care, and mouth care were not followed, as evidenced by the observations and interviews conducted. The Interim Director of Nursing (IDON) and CNAs acknowledged the importance of maintaining residents' personal hygiene to prevent infections and other health issues. The facility's failure to adhere to its own policies resulted in the observed deficiencies in resident care.
Inaccurate Documentation of RNA Tasks for Two Residents
Penalty
Summary
The facility failed to provide accurate documentation for two residents, Resident 73 and Resident 64, regarding their Restorative Nursing Aide (RNA) tasks. For Resident 73, the clinical records did not include documentation of passive range of motion (PROM) exercises to both legs and the application of an abductor pillow from March to May 2024. Despite physician orders and RNA Weekly Summaries indicating these tasks were performed, the Documentation Survey Report did not reflect this, leading to inaccurate records of the RNA services provided. Resident 73 was admitted with several diagnoses, including dementia, major depressive disorder, muscle weakness, and a left displaced femoral neck fracture. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on assistance for daily activities. Physical therapy evaluations showed limited range of motion in both hips and knees, and recommendations were made for RNA to perform PROM and apply an abductor pillow. However, the facility's documentation system failed to accurately record these tasks, as confirmed by interviews with the Regional Quality Assurance Nurse and the Physical Therapist. Similarly, for Resident 64, the facility's documentation did not accurately reflect the PROM exercises to both legs from February to April 2024. Resident 64 had a history of Type 2 diabetes, epilepsy, cerebral infarction, muscle weakness, and other conditions. The resident's therapy discharge summaries recommended PROM exercises, which were included in physician orders. However, the Documentation Survey Report indicated 'NA' or 'N' for these tasks, despite RNA Weekly Summaries showing they were performed. The Regional Quality Assurance Nurse and Restorative Nursing Aide confirmed the documentation system's limitations, which led to inaccurate records of the care provided.
Inadequate Laundry Equipment Maintenance and Monitoring
Penalty
Summary
The facility failed to ensure that one of its washing machines was functioning properly and that the temperatures of the washing machines and dryers were being monitored daily. During an observation and interview, it was noted that washing machine #4 was leaking water from the left side and the door. This issue was confirmed by the Assistant Administrator and the Maintenance Supervisor, who was unaware of the leak. Additionally, the Maintenance Supervisor admitted that there were no temperature monitoring logs for the washing machines or dryers, despite being responsible for checking these temperatures daily. Interviews with the Infection Prevention Nurse and the Interim Director of Nursing highlighted the importance of maintaining temperature logs to prevent the spread of infections. The facility's job descriptions for the Laundry Aide, Laundry Supervisor, and Maintenance Director indicated responsibilities related to the safe use and maintenance of laundry equipment. However, the lack of temperature monitoring and the unreported leak in the washing machine posed a risk of infection spread within the facility.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from Resident 209's responsible party before administering psychotropic medications. Resident 209, who was admitted with diagnoses including paranoid schizophrenia, atrial fibrillation, major depressive disorder, and anxiety disorder, was found to have moderately impaired cognitive skills. Despite this, the facility's records indicated that informed consent for psychotropic medications was obtained directly from Resident 209, who was unable to make medical decisions for themselves, as confirmed by the primary physician and registered nurse. The facility's policy requires that informed consent for psychotropic medications be obtained from the resident or their representative, especially when the resident lacks decision-making capacity. However, the informed consent form showed that Resident 209 was the one informed and consented to the medications, contrary to the facility's policy and the resident's documented inability to make medical decisions. This oversight in following the proper consent procedure potentially affected Resident 209's rights and self-worth.
Failure to Ensure Resident is Free from Unnecessary Physical Restraints
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary physical restraints. Specifically, the staff did not conduct an appropriate assessment for less restrictive measures before using physical restraints on the resident. The resident, who was at risk for falls, was observed with bilateral bolsters in place to prevent unassisted bed exits and potential falls. However, there was no documentation indicating that alternative measures were attempted prior to the use of these restraints. Additionally, the facility did not obtain a physician's order for the use of the bilateral bolsters as a restraint for the resident. The facility's policy and procedure for the use of restraints, which requires that restraints be used only after other alternatives have been tried unsuccessfully and with a physician's order, was not followed. The policy also specifies that restraints should not be used for the prevention of falls, yet the bolsters were used for this purpose without proper authorization or documentation.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source resulting in serious bodily injury for a resident with limited range of motion and mobility. The resident, who had diagnoses including dementia and major depressive disorder, was found to have a left displaced femoral neck fracture as indicated by X-ray results. Despite the resident's severely impaired cognition and dependency on assistance for daily activities, the facility did not report the injury to the appropriate State Agencies within the required two-hour timeframe, nor did they complete an investigation into the cause of the fracture in accordance with their Abuse Prevention policy. The resident had been receiving restorative nursing aide services for passive range of motion exercises and was noted to have stiffness in both hips, knees, and the right ankle. Over time, the resident's range of motion in the left hip and knee declined, leading to a recommendation for a physical therapy evaluation. Despite these observations and the eventual discovery of the fracture, the facility did not report the injury as required, resulting in a delayed investigation by State Agencies. Interviews with facility staff revealed that the resident did not complain of pain and had impaired cognition, which may have contributed to the lack of immediate recognition of the injury. The facility's Assistant Director of Nursing and Administrator acknowledged that the injury should have been reported within two hours of discovery, but it was not reported due to the age-indeterminate nature of the fracture. The facility's policy required reporting of injuries of unknown origin to rule out abuse, but this was not adhered to, leaving the resident and others at risk for potential abuse, neglect, or mistreatment.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for Resident 194, who was at risk of choking and aspiration due to dysphagia. Resident 194 was admitted with multiple diagnoses, including schizophrenia, dementia, major depressive disorder, and lack of coordination, and required a mechanically altered diet. The resident's care plan and physician's orders specified a mechanical soft texture with thin liquid consistency diet, including pureed vegetables and fruits. On the day of the incident, Resident 194 was mistakenly served a regular fortified diet intended for their roommate, which did not meet the required texture modifications. This error was observed by a Certified Nurse Assistant (CNA) who noted that the resident was eating a meal with a consistency that could lead to choking. The CNA acknowledged that the wrong tray was served and that the resident's name should have been checked before serving the meal. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), Registered Dietitian (RD), Speech Therapist (ST), and Interim Director of Nursing (IDON), confirmed the error and highlighted the importance of adhering to the prescribed diet for safety reasons. The facility's policies on therapeutic diets and dysphagia management emphasized the need for mechanically altered diets to prevent airway obstruction, which was not followed in this instance.
Resident Injury Due to Improper Positioning Near Bedside Drawer
Penalty
Summary
The facility failed to ensure a safe environment for Resident 87, who was at high risk for falls and injuries due to conditions such as muscle weakness, stroke, vascular dementia, and cognitive communication deficit. The resident was admitted with severe cognitive impairments and required substantial assistance with bed mobility. During a repositioning incident, the resident hit their head on a bedside drawer, resulting in a laceration on the forehead. This incident occurred because the staff did not adequately recognize the bedside drawer as a potential hazard during the repositioning process. Observations and interviews revealed that the staff, including CNAs and LVNs, were aware of the risks associated with improper positioning of residents near furniture. CNA 5 demonstrated the correct method of repositioning, emphasizing the need to keep the resident away from the bedside drawer. However, during the incident, CNA 7 failed to pull the resident closer before turning, leading to the injury. The staff acknowledged the importance of maintaining proper body mechanics and ensuring the resident's safety by removing or avoiding obstacles during repositioning. The facility's policy on Safety and Supervision of Residents emphasizes the importance of preventing accidents and training employees to identify and report potential hazards. Despite this policy, the incident with Resident 87 highlights a lapse in executing these safety measures, as the staff did not adequately prevent the resident from hitting the bedside drawer during repositioning. The failure to maintain a hazard-free environment and provide adequate supervision placed the resident at risk for injury.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that 45 out of 95 resident rooms met the required space standards, with multi-bed rooms needing at least 80 square feet per resident and single rooms requiring 100 square feet. Specifically, 43 rooms in the Palm Unit were identified as having less than the required 80 square feet per resident, with each room measuring 223.53 square feet and accommodating three residents. Additionally, two rooms in the Palm [NAME] East Unit were found to be below the required 100 square feet for single occupancy. These deficiencies were identified during a review of the facility's Client Accommodations Analysis form and were confirmed through observations conducted over a three-day period. Despite the space limitations, observations noted that residents had sufficient room to move freely within their rooms, with adequate space for beds, side tables, and the use of mobility aids such as wheelchairs, walkers, or canes. The facility's policy and procedure, last revised in May 2017, stipulates that bedrooms should accommodate no more than two residents and meet the specified square footage requirements to ensure full visual privacy and adequate nursing care. However, the current room configurations did not align with these policy requirements, potentially impacting the provision of safe nursing care and privacy for the residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,152 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Artesia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Artesia Christian Home Inc. | 0.8 mi | ★★★★★ | 24 | 0 |
| Cottage Crest Post Acute | 2.1 mi | ★★★★★ | 4 | 0 |
| Cerritos Vista Healthcare Center | 2.3 mi | ★★★★★ | 43 | 0 |
| Villa Del Sol Post Acute | 2.4 mi | ★★★★★ | 8 | 0 |
| The Springs Post-acute | 2.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.